Joint Petition, Agreement, and
and Judgment and Decree For
Marriage Dissolution
Without Children
,
Name of Wife (First, Middle, Last)

1. Information about Husband:

Full Name:
First Middle Last

Address:
Street Address Apt. No.

City County State Zip Code

Date of Birth: __________________________

Month Day Year

Husband’s former or other names:
(Or write “none”) First Middle Last

Husband’s social security number is listed on Confidential Form 11.1 and submitted
along with the Joint Petition.

2. Information about Wife:

Full Name:
First Middle Last
Address:
Street Address Apt. No.

City County State Zip Code

Date of Birth: __________________________
Month Day Year

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Wife’s former or other names:
(Or write “none”) First Middle Last

First Middle Last

Wife’s social security number is listed on Confidential Form 11.1 and submitted along
with the Joint Petition.

3. Children: “Minor” children are under age 18, or under age 20 but still in high school.

a. Do Husband and Wife have minor children together? YES NO

(If YES, you are using the wrong forms.)

b. Do Husband and Wife have any adult dependent children who are not able to support

themselves because of a physical or mental condition? YES NO

(If you answered YES, you may ask the court to make an order regarding support for the adult

dependent, but you should use the Marriage Dissolution with Children forms to do this.)

c. Has wife given birth, since marrying Husband, to a child who is not Husband’s child?

YES NO

If you answered NO to c, skip to d. If YES, continue below:

i. Fill in the information for all children born to Wife since marrying Husband, who are

not husband’s biological children.

Full Name of Child Date of Birth Age

ii. Is there a court order naming someone other than the Husband as the father of the

child(ren) listed in (i)? YES NO If YES, fill in:

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Full Name of Child Date of Court County/State of Order Court Case No.
Order

iii. Have the Wife and biological Father signed a Minnesota Recognition of Parentage

(ROP) for any of the children listed in (i) above? YES NO

If YES, state the full name of the child:

and attach to the Petition a certified copy of the Recognition of Parentage.

Has the Husband signed the “Husband’s Non-Paternity Statement” for any of the

children listed at (i) above? YES NO

If YES, state the name of the child:

and attach a certified copy of the “Husband’s Non-Paternity Statement.”

Stop: For each minor child listed at c.(i.) you must have a court order OR the Recognition of

Parentage and Non-Paternity Statement to use the Dissolution Without Children forms.

Otherwise, use the Marriage Dissolution with Children forms.

d. Is Wife pregnant? YES NO UNKNOWN (If the Wife is pregnant

you are using the wrong form. Use Marriage Dissolution with Children.)

4. Our Marriage

Husband and Wife were married on: (month, day, year)

in the City of , County of , State

of , Country of

5. 180 Day Requirement

Husband has been living in Minnesota for the past six (6) months: YES NO

Wife has been living in Minnesota for the past six (6) months: YES NO

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6. Armed Forces

Husband is an active member of the armed forces: YES NO

If YES, has the member of the armed forces been stationed in Minnesota for the past six

(6) months? YES NO

Wife is an active member of the armed forces: YES NO

If YES, has the member of the armed forces been stationed in Minnesota for the past six

(6) months? YES NO

7. Marriage Cannot be Saved

There has been an irretrievable breakdown of our marriage relationship.

8. Physical Living Situation

Do Husband and Wife live together at this time? YES NO

If NO, the date of separation was: .
Month Day Year

If YES, Husband and Wife are living together at this time because:

9. Other Proceedings

A separate court case for dissolution, legal separation or annulment has already been

started by Husband or Wife in Minnesota or another state: YES NO

If YES, the type of court case is: and it was started in

County in the State of and the Court file

number is , and the outcome of the case is Open

Closed Unknown or .

10. Protection or Harassment Order

An Order for Protection or a Harassment/Restraining Order is in effect regarding

Husband and Wife: YES NO If YES, the Order protects: Husband

Wife. The Order was filed in County on the

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date: , and the Court file number is

Month Day Year

A copy of the Order is submitted along with this Joint Petition.

11. Public Assistance: (Note: If either person is receiving public assistance from the State of Minnesota or

applies for it after this proceeding is started, notice of this marriage dissolution action must be given to the

county’s collections and support office. See Minnesota Statutes Section 518A.44)

a. Husband receives public assistance from the State of Minnesota: Yes No

If YES, the assistance is from_______________________County. (check all that apply)

MFIP in the amount of $ per month.

Tribal TANF in the amount of $ per month.

General Assistance in the amount of $ per month.

Medical Assistance

Child Care Assistance

MinnesotaCare

b. Wife receives public assistance from the State of Minnesota: Yes No

If YES, the assistance is from ______________________County. (check all that apply)

MFIP in the amount of $ per month.

Tribal TANF in the amount of $ per month.

General Assistance in the amount of $ per month.

Medical Assistance

Child Care Assistance

MinnesotaCare

12. Husband’s Employment

a. Husband is employed: Yes No Husband is self-employed: Yes No

b. Husband works at least 40 hours per week: Yes No

If Husband is unemployed or working less than 40 hours / week, answer these

questions:

i. Why is Husband unemployed or working less than 40 hours / week?

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ii. What is Husband’s past work experience (type of jobs, hours, pay, length of time at

the job) and what are Husband’s professional qualifications or licenses?

c. Current Employment: (if Husband currently has more than two jobs, use an attachment for the

additional jobs.)

Name of Husband’s Employer (If self-employed, list name and business address)

Employer’s Street Address

City State Zip Code

Name of Husband’s Employer if self-employed, list name and business address)

Employer’s Street Address

City State Zip Code

st nd
Questions about Current Jobs 1 Job 2 Job

Is Husband paid by the hour or hourly salary hourly salary
salaried?

What is the average number of
hours Husband works per week?
________________hours ________________hours

How much overtime pay does
Husband receive per week on
$_____________________ $____________________
average?
Does Husband receive bonuses? If Yes, how much was received If Yes, how much was received
st in bonuses last year? in bonuses last year?
Yes No 1 Job
$_____________ $_____________
Yes No 2nd Job How much does Husband expect How much does Husband expect

to receive this year? to receive this year?
$___________ $___________

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13. Husband’s Income

Source of Income Amount Per Month (or zero) before deductions/taxes

Self Employment Income $______________ per month

Self Employment income means gross receipts minus costs of goods sold

minus ordinary and necessary business expenses.

Job with __________________________ $______________ per month

Monthly income from a job = Hourly wage x Hours worked per week x 4.33 (weeks per month)

Second Job with _____________________ $______________ per month

Third Job with ______________________ $______________ per month

Commissions from all jobs $______________ per month

Divide the total amount you expect this year by 12 to get a monthly average

Enter the amount of child support Husband is court-ordered
to pay for any nonjoint child(ren) $______________ per month

Enter the amount of spousal maintenance Husband is court-ordered
to pay to a current or former spouse $______________ per month

14. Wife’s Employment

a. Is Wife employed? YES NO Is Wife self-employed? YES NO

b. Is Wife working at least 40 hours per week? YES NO

If Wife is unemployed or works less than 40 hours/week, answer these questions:

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i. Explain why Wife is not working or why Wife works less than 40 hours/week

ii. What is Wife’s past work experience (type of jobs, hours, pay, length of time at the

job) and professional qualifications or licenses?

c. Current Employment: (If Wife has more than two jobs at this time, use an attachment for the

additional jobs.)

Name of Wife’s Employer (If Self-Employed list name and business address)

Employer’s Street Address

City State Zip Code

Name of Wife’s Employer (If Self-Employed list name and business address)

Employer’s Street Address

City State Zip Code

st nd
Questions about Jobs 1 Job 2 Job

Is Wife paid by the hour or salaried? hourly salary hourly salary

What is the average number of ________________hours ________________hours
hours Wife works per week?

How much overtime pay does Wife
receive per week on average?
$_____________________ $____________________

Does Wife receive bonuses? If Yes, how much did Wife If Yes, how much did Wife
receive in bonuses last year? receive in bonuses last year?

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st
Yes No 1 Job $____________________ $___________________
nd How much does Wife expect How much does Wife expect to
Yes No 2 Job
to receive this year? receive this year?
$____________________ $___________________

Court issue a final judgment and decree terminating our marriage and ordering the terms of this

Agreement.

READ and SIGN the Verification and Acknowledgments.

STATE OF MINNESOTA )
) SS
COUNTY OF )
(County where documents signed)

Verification and Acknowledgments

a. I have read this document. To the best of my knowledge, information and belief the
information contained in this document is well grounded in fact and is warranted by
existing law.

b. I have not been determined by any Court in Minnesota or in any other State to be a
frivolous litigant and I am not the subject of an Order precluding me from serving or
filing this document.

c. I am not serving or filing this document for any improper purpose, such as to harass the
other party or to cause delay or needless increase in the cost of litigation or to commit a
fraud on the Court.

d. I understand that if I am not telling the truth or if I am misleading the Court or if I am
serving or filing this document for an improper purpose, the Court can order me to pay
money to the other party, including the reasonable expenses incurred by the other party
because of the cost of serving or filing this document, Court costs, and reasonable
attorney’s fees.

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e. WAIVER (Rule 306.01(c)): I know I have the right to be represented by a lawyer of my
choice. I hereby expressly waive that right and I freely and voluntarily sign the foregoing
stipulation.

DATE: DATE:

Signature of Husband Signature of Wife
(Sign only in presence of notary public) (Sign only in presence of notary public)

The foregoing facts were found BY THE COURT
by me after due hearing and the
Order thereon is recommended.

District Court Referee Judge of District Court

Dated: Dated:

Judgment

I certify the above constitutes the Judgment of the Court and Judgment is hereby entered.

Court Administrator

Deputy

Dated:

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Attachment “A”
DIVISION OF ASSETS AND VALUE

Husband’s Name:

Wife’s Name:

1. We agree on how to divide our assets (everything we own and that is owed to us).
2. Each person shall receive as their own all assets in their column.

Definitions: Current Fair Market Value is an estimate of the amount of money you could get
if you sold the item to a stranger, such as through a newspaper advertisement. It does not mean
what you paid for it originally, and it does not mean what it would cost you to replace it if you
lost it. If you are still paying for an item, list it in husband’s or wife’s column at the present
value.
Present value means the current fair market value minus the amount you still owe.

Who Gets the Item and What is the Value
*Enter the current fair market
value or present value of the item in
DESCRIPTION OF ASSETS the column of the person getting the
item.
 If you do not have the type of property described, enter a zero

in the columns for Husband and Wife.

 To avoid confusion at a later date, describe each item as clearly
as possible. For example, include the last 4 digits of account *HUSBAND *WIFE
numbers (xxx2873), names of banks, & whose name is on the
title or account, if applicable.

 List all property owned separately or together, no matter when
it was acquired, except do not list the non-marital property
described at #3 of the Joint Petition.
Cash on hand: $ $

Date we filled out this form:
1. We agree on how to divide our marital debts (debts we have incurred since our marriage date,
either separately or together).
2. Each person shall pay as their own the debts listed in their column, and shall not ask the other
person to pay these debts/bills.
3. We have listed all marital debts we know of on this Attachment. Any debts incurred by one of
us alone and not listed on this Attachment shall be paid by the person whose name is on the
debt/bill.
*Write the current amount
DESCRIPTION OF DEBT(S) owed in the column of the
 If you do not have the type of debt described, enter a zero in the person who will pay it.
columns for Husband and Wife.

 To avoid confusion at a later date, describe each debt as clearly *HUSBAND *WIFE
as possible. For example, state who the debt is owed to, whether
husband’s or wife’s name is on the debt, and the last 4 digits of
account numbers (xxx3094), if applicable.

 List all debts in husband’s name alone and in wife’s name alone
and in both names together. Include debts incurred during the
marriage and after separation. Do not include bills you pay in
full each month.